Beyond the Needle: Unmasking Atypical Mycobacteria in Postvaccination Abscesses in Children.

Introduction: Atypical or nontuberculous mycobacteria (NTM) are an environmental organism responsible for opportunistic infection. Rapid-growing NTM are more commonly associated with hospital-acquired infections. Many of the organisms responsible for diseases in immunocompromised patients and hospital-acquired infections originate from tap water, such as Mycobacterium kansasii, Mycobacterium xenopi, Mycobacterium gordonae, Mycobacterium simiae, Mycobacterium mucogenicum, Mycobacterium fortuitum, Mycobacterium chelonae, and Mycobacterium abscessus. NTM is a rare organism responsible for the injection abscess. Considering low incidents, not much clinical data are available for this condition. Here, we discuss such cases which can be helpful to spread awareness and provide data for future policy makers. Materials and Methods: This was a retrospective study. Data on patients with injection abscess were collected from the last 6 years. Detailed history and clinical examination findings were analyzed. Children with injection abscess were operated and their further management and outcome were studied. Results: A total of 13 cases with confirmed culture of NTM were treated over 6 years. The age ranged from 2½ months to 5¾ years with male:female ratio of 7:6. All patients hailed from the same geographical area. All children were healthy with no history of any long-term or chronic illness, without additional symptoms and had received Bacillus Calmette-Guérin vaccination at birth. The total duration of illness varied from 1 to 5 months, with a mean of 3 months. All patients had a history of intramuscular age-appropriate vaccination as per the national immunization schedule. All patients were followed up to 6 months after intervention and none of our patients developed relapse. Conclusion: Patient who does not respond with optimum treatment should have a high suspicion of such opportunistic infection, which is crucial to their management. Hospital-acquired NTM infections often result from contaminated instruments or fluids. Adherence to strict aseptic precautions, hand hygiene and environmental precautions are the key to preventing these infections. In case of skin and soft tissue infections / abscesses, surgical intervention plays a significant role for managing the patient.

Total Glans Amputation in a Child following Ritual Circumcision - Report of a Case and Review of Literature.

Ritual circumcision in children remains a trivialized procedure in some countries, especially in rural areas. It is often performed by unqualified paramedical personnel, or even by religious workers whose notions of surgery and asepsis are uncertain. Although it is thought to be a minor procedure, major complications with sexual or even life-threatening prognosis can occur. Amputation of the glans during circumcision is a rare incidence secondary to poor application of operating principles. We report the case of a 1½-year-old boy who underwent a progressive amputation of the glans after a ritual circumcision by a religious worker. The child was brought 10 days after the procedure with totally amputated, nonsalvageable glans. A urethral meatoplasty was performed to enable proper voiding and prevent meatal stenosis. The child has been in follow-up for the past 6 months without any urinary symptoms.

Intraperitoneal Rupture of Urinary Bladder during Micturating Cystourethrography in a Child.

Micturating cystourethrography (MCUG) is a very commonly performed diagnostic procedure in pediatric urology. Although considered to be simple, safe, and cost-effective, it can incur some complications. Bladder rupture during MCUG is a very rare complication and only a handful of cases have been reported in world literature. We report the case of a 2.5-month-old boy who had intraperitoneal bladder rupture during an MCUG needing surgical repair. At operation, the child had a bladder tear at the dome of the bladder which was repaired successfully. The postoperative recovery was uneventful and the child is doing well in follow-up. Although individual management of bladder rupture may differ, a majority of infants need surgery for the same. Thorough vigil and attention to the technique are a must to prevent such incidents in children.

Intraperitoneal bladder rupture in a 1 year old: A very unusual accident.

Intraperitoneal bladder rupture is a rare event in the paediatric population. Road traffic accidents (RTA) and seat belt injuries are considered to be the main cause for the same. We report an interesting case of a 1-year-old girl who had a laparoscopic repair of intraperitoneal bladder tear following a non-RTA injury. This is the smallest child where intraperitoneal bladder rupture was repaired laparoscopically. This mechanism of injury-causing bladder rupture has also not been reported across world literature. The child was sleeping on the floor near the bed with her mother. The father who was sleeping on the bed accidentally fell onto this child. Imaging showed large amount of clear intraperitoneal fluid with no organ injury. Laparoscopy showed a 3.5 cm long tear on the posterior wall of the bladder. The tear was repaired using 3 mm instruments.

Measurement of Body Temperature in Postsurgical Children: Comparisons of Infrared Nonskin Contact Digital Thermometer, Skin Contact Digital Thermometer, and Mercury in Glass Thermometer.

CONTEXT: Postoperative fever is known to occur after all surgical procedures irrespective of the type of anesthesia. Thermometry devices that work without touching or disturbing the child seem to be appreciated more than the conventional skin contact thermometers. However, whether this technology is reliable to be adapted for routine pediatric surgical care is debatable. AIMS: The aim of this study was to study the accuracy of infrared nonskin contact digital thermometer (IRT) compared to the skin contact digital thermometer (DT) and mercury in glass thermometer (MT). SETTINGS AND DESIGN: A prospective cross-sectional study was done in postoperative patients at a pediatric surgical center over a period of 3 months. SUBJECTS AND METHODS: The forehead temperature was recorded with IRT. This was followed by recording the temperature in one armpit by DT and the other armpit by MT. Readings were promptly documented. STATISTICAL ANALYSIS USED: A sample t-test was done which gave the P value and mean. Linear regression analysis was carried out to find correlation coefficients. Bland-Altman test was used to access the concordance between all readings. RESULTS: We found a strong correlation between temperature readings taken by DT (mean = -0.03, r = 0.07, slope = -0.04) and IRT (mean = 0.89, r = 0.091, slope = -0.14). However, on comparison of results with the MT, there are wider limits of agreement with the IRT (-0.31-2.09) in comparison to DT (-0.66-0.59). CONCLUSION: Skin contact digital thermometer are more accurate and suitable for checking body temperature as compared to infrared nonskin contact digital thermometer in postoperative pediatric patients.

Generalized Lymphangioma of the Tongue: A Rare Cause of Macroglossia.

Generalized lymphangioma of tongue is a rare cause of macroglossia in children. It causes mechanical discomfort and functional and psychological disturbances. We report a case of macroglossia due to generalized lymphangioma in a 10 year old where partial glossectomy was done to achieve symptomatic relief.

Congenital Segmental Dilatation of Jejunum: A Rare Entity.

Segmental dilatation of the intestine is a rare disease and mostly involves the ileal segment. It commonly presents in the neonatal period and early infancy with symptoms of partial or total obstruction. We report a rare case of an isolated jejunal segmental dilatation in a 7-year-old girl. The child presented with malnutrition and signs of subacute obstruction. The diagnosis was confirmed intraoperatively, and the dilated segment was resected. Although the etiology remains unknown, we discuss its clinical aspects and relevant literature.

Littoral Cell Angioma: A Rare Cause of Pediatric Thrombocytopenia.

Littoral cell angioma is a rare primary splenic vascular tumor, originating from the littoral cells lining the red pulp sinuses of the spleen, with variable presentation. Here, we present the case of a 2-year-old male child presenting with chronic thrombocytopenia which resolved after splenectomy.

Pediatric Chylopericardium: Treatment Conundrum.

Primary chylopericardium is a rare entity in the pediatric population, which is characterized by chyle accumulation in the pericardial sac. Treatment of this rare problem is a management dilemma as no definitive treatment has been found to be curative. We share our experience of treating chylopericardium with minimally invasive surgery.

Esophageal achalasia and alacrima in siblings.

Achalasia of the esophagus is a rare problem in children. It has been reported in siblings of consanguineous parents. Allgrove or AAA (triple-A) syndrome is an autosomal recessive condition associated with adrenal insufficiency, alacrima and achalasia of the oesophagus. We present two siblings with familial achalasia and alacrima treated at 3 months and 9 years respectively.

Impalpable testes--is imaging really helpful?

The study evaluated the role of imaging studies in the diagnosis of impalpable undescended testes. A total of 40 children referred with 45 impalpable undescended testes had an ultrasound scan and clinical examination by a pediatric surgeon. 22 out of these 45 testes were found to be palpable on clinical examination by a pediatric surgeon. Of the remaining 23 boys (23 units of testes), 21 underwent MRI scan for identification of testes and results were compared with findings at laparoscopy. The diagnostic agreement of ultrasound and MRI in correctly localizing the testes was 19% and 52% respectively whereas the sensitivity of detection was 60% and 55% respectively. Imaging studies therefore have a limited role in pre-surgical evaluation of boys with impalpable testes.

Cutaneous mucormycosis in children.

Cutaneous mucormycosis is a rare fungal infection in children. It is commonly found in immunocompromised children. Early diagnosis is difficult and requires a very high degree of suspicion. Recommended mainstay of treatment has been amphotericin B and extensive surgical debridement which may at times require amputation if limb is involved. The authors share their experience of two cases of successfully treated cutaneous mucormycosis.

Laparoscopy in diagnosis of prolonged neonatal jaundice.

When managing neonatal jaundice, there is no single test or imaging modality that can reliably define biliary atresia and neonatal hepatitis. Early diagnosis is an important step for surgical success in extra hepatic biliary atresia. In many situations, exploratory laparotomy and operative cholangiography may be needed to settle the definitive diagnosis, with the risk of having negative exploration in those high risk patients with medical etiology. The use of laparoscopy may help in avoiding unnecessary exploration for such group of patients and arriving at a definite diagnosis. Six patients with conjugated hyperbilirubinemia were evaluated with a diagnostic laparoscopy, laparoscopic cholangiography and liver biopsy. Three of the six patients were diagnosed to have neonatal hepatitis and so an unnecessary laparotomy was avoided in these cases.

Down syndrome with transient myeloid leukemia and urological abnormality.

Among the various anomalies associated with Down syndrome, leukemia is quite common. The variant transient myeloid leukemia is seen almost exclusively in the Down syndrome patients. On the other hand, urological anomalies are infrequently found both in the Down syndrome and leukemia patients. We report a case who had the rare combination of a urological anomaly along with Down syndrome and transient myeloid leukemia.

Thoracoscopy in management of empyema thoracis in children.

The usual treatment for empyema in children varies from a simple thoracocentesis to thoracotomy and open decortication. We studied the role of thoracoscopy in the management of empyema thoracis in 10 immunocompetent children after failure of medical management. All children recovered well with an early removal of intercostal tube and reduced postoperative hospital stay and showed complete resolution of empyema on follow up. Thoracoscopy has come as a new ray of hope for the patients with empyema, with the advantages of complete evacuation, minimal pulmonary dysfunction, reduced pain and hospital stay.

Minimally invasive surgery.

The field of Minimally Invasive Surgery or Minimally Access Surgery (MAS) as it is commonly known has grown remarkably over the past two decades. MAS has a steep learning curve and unexpected complications with MAS are not infrequent unless approached with great caution. However it leads to a shorter hospital stay, less analgesic use, rapid return to school and a better cosmetic outcome. MAS in children started in India a decade ago, and has a great impact on the way we manage pediatric surgical problems today. This article is a brief description of most of the procedures that are being done with the help of MAS. In addition to these, new techniques, procedures and innovations are always ongoing in this fast developing field. MAS is being practiced in limited centers in our country with expanding experience and indications. Its use in children as the first option for early appendicitis, intraabdominal testis, gall stone disease and a few other conditions is now proven beyond doubt. There are other indications and areas of application of MAS which are continuously evolving and needs institutional audit and validation at every step before moving to the next phase.